Yes, insurance is often confusing and challenging. But there are a few things you can do to help you make your way through the confusion and to make sure you get the benefits you deserve. We do our best to work with you and your insurance company to maximize your insurance benefits.
1. Remember that insurance is a contract negotiated between your employer and the insurance company. The contract or policy outlines covered dental or medical benefits, as well as non-covered and excluded services. Every plan is different, so be sure your plan fits your wants and needs.
2. Know your insurance limits and restrictions.
3. Be aware of who the insurance provider is for your dental and medical plans.
4. Know your co-pays for different routine services such as office visits and consultations.
5. Have the most up-to-date information available regarding your insurance.
6. Be aware of your yearly deductibles and maximums.
7. When a treatment plan is presented, call your insurance provider to see what your benefits are so that you can be assured of what’s available to you.
8. When you receive your Explanation of Benefits (EOB) in the mail, call your insurance company if you have any questions.
9. Know effective dates of coverage and cancellation dates for plan benefits.
10. This one is to prepare you for one of the thornier challenges that await all of us when dealing with the health insurance industry today. The issue is PREDETERMINATIONS:
PREDETEMINATIONS, which are initial estimates of and approval for payment by your insurance carrier for a specific procedure, prior to treatment, are NOT A GUARENTEE OF COVERAGE OR PAYMENT by the insurer. This is particularly true of medical claims. All PREDETERMINATIONS are provided by the insurance company with a disclaimer stating that the decision for final payment will be made AFTER THE CLAIM IS SUBMITTED. So while obtaining a predetermination is a useful guide and a good indication that payment will be made for a specific procedure, until the actual claim is submitted – which is always after the procedure has been performed – there are no guarantees. We work as hard as we can to help you through this maze, but in the end it is the insurance company which makes the decision. The unfortunate truth is that from time to time insurance companies do in fact reverse their original decisions. If you want us to submit a perdetermination to your insurance company on your behalf, please let us know and we will work diligently to make it work. As a rule, the insurance companies require 45 days from the time they receive the predetermination to process the request.